The return of the Aids plague

If you’re going to contract HIV, make sure you do so in a well-heeled corner of Europe or north America. You will have the benefit of drugs that may well delay the onset of Aids and ease many of the worst symptoms of the disease. Compared with two decades ago, you will be relatively free from stigma: politicians and basketball stars can reach the pinnacle of their careers despite being HIV-positive. With a bit of luck, you will find a treatment programme that will afford you a full life.

But if your postcode falls in the poorer regions of Africa, Asia or Latin America, just don’t, whatever you do, have unprotected sex with your husband or a stranger, undergo vital surgery or a blood transfusion, shoot up, or give birth with any expectation that your child will survive. HIV is likely to be a death sentence: your chances of receiving treatment are roughly the same as the chances of picking an ace at random from a deck of cards.

In June 2005, the World Health Organisation and the Joint United Nations Programme on HIV/Aids (Unaids) estimated that of the 6.5 million people in developing countries in need of antiretroviral (ARV) drug treatment for Aids, only 15% were receiving them. The bulk of the untreated were in sub-Saharan Africa, home to 10% of the world’s population and 60% of all people living with HIV.

Also in openDemocracy’s debate “HIV/Aids: what policy for life?”:

Chris Marrow, Ring a Ring o’ Roses: Malawi’s dance of death (February 2003)

Hugh Brody, “Botswana, the Bushmen/San, and HIV/Aids” (August 2003)

Donna Hughes, “The ‘ABC approach’ to global HIV/Aids: good for women and girls” (August 2004)

If you find this material valuable please consider supporting openDemocracy by sending us a donation so that we can continue our work and keep it free for all

Now, the intolerant strands of the Christian right might be correct: perhaps poor people simply do not have the moral fibre to stop themselves wantonly getting Aids. In any case, as we know from rock-solid sources, even if you can get hold of a condom and are prepared to risk damnation to use it, they have holes in them.

But outside that thorniest of moral mazes, once you have contracted HIV, most people agree that you should be treated. Generally, that involves ARVs, which work by slowing the rate at which the virus reproduces. The treatment relies on adherence and readily available supplies: patients must take 95% of their medication for it to be effective. It does not send the virus into remission: ARVs are for life, not just for Christmas.

And that life can be transformed. ARVs allow people who would otherwise be largely incapacitated by chronic lesions and chronic diarrhoea to go to school, to work, to provide for families. Without ARVs, one in every two HIV-positive children in developing countries dies before his or her fifth birthday. The snag, if you are one of the 40 million people living with Aids, is that ARVs are not cheap.

Brazil’s example

“The problem continues to be that economic interests take precedent over public health,” says Felipe Garcia de la Vega, a paediatrician and Aids expert with the Access to Essential Medicines campaign at Médecins Sans Frontières (MSF).

MSF treats 40,000 Aids patients in twenty-nine countries. Its programmes rely on generic ARVs – versions of patented drugs produced without regard for profit. Generics also allow governmental Aids outreach projects in the United States to function. They often cost a fraction of the prices charged by pharmaceutical corporations.

In 1996, the Brazilian government pledged to provide universal access to free Aids treatment. The system has become the benchmark in national Aids projects, and with good reason. Deaths from the disease have halved; the rate of infection is half that projected by the World Bank in 1998. But as the goal of universal access comes closer and the costs of the programme soar, Brazil has become the theatre in which progressive reformers have locked swords with Big Drugs.

The Brazilian state-owned drugs company, Farma Manguinhos, produces only 20% of the ARVs required to treat the country’s 600,000 HIV patients. Brazil spends a further $107 million each year buying a drug called Kaletra from pharmaceutical giant Abbott Laboratories. This it is obliged to do because, as a member of the World Trade Organisation (WTO), Brazil must bow before intellectual property law. Pharmaceutical companies can patent a drug, which allows them to control its release for a limited period of time.

Emboldened, perhaps, by the recent victories in Argentina and Bolivia against Big Debt and Big Water respectively, Brasilia has squared up to Abbott, toughening a stance it first assumed in 2001. It threatened to break the Kaletra patent and produce a generic version – which it is entitled to do under WTO rules only in the event of a “national emergency” – if Abbott did not cut its prices. In the United States, the dragoons of patent law went berserk. Brazil’s effrontery, commentators protested, was akin to that of such scapegraces as Iran, Cuba and Venezuela (see Mary Anastasia O’Grady, “Brazil Mulls Drug Patent Theft as an AIDS Antidote”, Wall Street Journal, 24 June 2005).

In July, Brazil’s new health minister José Saraiva Felipe scotched rumours of a deal. The most probable outcome, following a summit with Brazil’s embattled president, Luiz Inácio Lula da Silva, on 10 August, is that Brazil’s threat will remain just that and that Abbott will freeze the price of Kaletra sold to Brazil for the next six years. That will save Brazil $259 million, which, compared to net sales of $19.6 billion in 2004, is no skin off Abbott’s nose. But, somewhat unusually for pharmaceutical corporations, Abbott has started talking about principles.

“Intellectual property should be respected”, says Michelle Johnson at Abbott’s Illinois headquarters. Doing so, she reasons, is the only way to ensure corporations recoup their research and development costs, enabling them to continue to develop new drugs. Patents, she says, are “in the best interests of patients.” Abbott’s official statement puts it thus:

“Brazil has the ninth largest economy in the world, and it is reasonable to expect a country this large and prosperous to carry its fair share of the burden for scientific advancement and investment. Beating HIV requires cooperation and coordination among governments, health care providers, non-governmental organisations, companies, and the people of every nation.”

Patenting the future

The problem with that argument, says Vandana Shiva of the Research Foundation for Science, Technology and Natural Resource Policy in Delhi, is that it’s rubbish.

“The corporations simply use information that’s already in the public domain or lift from academic papers,” says Shiva, who has spent fifteen years in American and European courts trying to prise corporate fingers from medical patents. She cites the case of the gene that controls the way in which HIV infects cells. It was identified by Robert Gallo’s research team in 1995, but Maryland-based Human Genome Sciences was awarded the patent. Pioneering academics do the work, companies make the dough. “We have to break the myth that patent-holders are the inventors”, says Shiva. “In reality, it’s piracy.”

Moves to limit the production of generic ARVs in Shiva’s native India, sparked worldwide protests. The producer of 70% of the planet’s generic ARVs, India, joined the WTO in 1995. The WTO’s agreement on Trade-related Aspects of Intellectual Property Rights grants effective monopolies to multinational pharmaceutical companies and has the effect of stifling competition in generics – the factor that has kept prices low. In the first five years of this century, generic production brought the price of ARV treatment down from $10,000 per year per patient in 2000 to as little as $150 today.

The future is not bright. As viruses are wont to do, Aids mutates. In Europe, where treatment programmes were rolled out early in the epidemic, patients who became resistant to ARVs have been moved on to “second-line” treatments, such as Kaletra. Necessarily, second-line ARVs are new drugs, and thus much more expensive.

With a view to this impending budgeting crunch, a united front of Latin American health ministers at a meeting in Buenos Aires on 5 August secured a two-thirds reduction in the prices they pay for corporate Aids drugs. But that will not weaken the hegemony of the patent. If Aids programmes in poor countries are denied cheap generic second-line treatments, epidemiologists warn, they will collapse. Aids will be a plague once more. That makes a nonsense of the UN Millennium Development Goal to “provide access to affordable essential drugs in developing countries” by 2015.

Vandana Shiva wonders what became of Indira Gandhi’s vision for the future of medicine. In May 1981, India’s then prime minister gave what now looks like a doomed prognosis. Her “idea of a better world” was “one in which medical discoveries would be free from patent and there will be no profiteering from life and death.”